Tell-tale smudges

It’s only when you look really closely at the family cartological heirlooms, the yellowing atlases from the early 20^th century, that the changes startle. Many of the outlines are familiar (plate tectonics and continental outlines metamorphosing at a dawdle by comparison) but closer scrutiny of the borders takes you into alien territory. It’s as if a giant eraser has been applied to scrub out the (deceptively brittle) barrier lines (colonial remnants from the bad old days) and left spaces for refreshed a la mode versions. Yet, there are still borders each, somehow, epitomising territory, geographical, philosophical, each making a statement of both adherence to tradition and, each to an extent, introverted.

Personal space

Any medical examination has the potential to evoke sensitivities, social, anthropological and clinical, the probability related in part to gender of the examiner and examined and age of the latter. Rebecca Moon (Southampton) and colleagues’ study of and discussion around the perceptions of pubertal examination re-opens the for-long-barely-ajar door on this area, specifically the need or not, for chaperones. Though more male paediatricians were likely to request a chaperone for female examinations, this was far from universal. Not recording the name and title of the chaperone or reliance on and parents as proxies was widespread. Not all adolescents of course want a ménage à trois (previous work suggesting that preferences are bidirectional), but not providing at least the option is a clear risk of exposure. See page 31

Before the sentinel episode

For many reasons (some with a degree of validity) barriers to new implementing screening programmes are daunting. Fulfilling the criteria (prevalence, treatability, predictive value of the test, acceptability) is the ‘easy’ part. Human behaviour being the innately conservative beast it is, results in changes at policy level being, inevitably, stodgy. Well, near inevitably, pandemic accelerated change in vaccine policy being the outlier par excellence. What happens when your index illness is, at the soonest, some years off on the horizon line. Owen Bendor-Samuel and colleagues (Oxford) describe the background to and success of the UK INGR1D diabetes genotype susceptibility study. Based on the premise that certain polymorphisms disrupt (T cell mediated) immune self-tolerance early in life and, in the case of type one diabetes manifests as insulin antibodies, they sought to test the acceptability and predictive value of piggy backing an additional multiple SNP spoke to the neonatal blood spot. A remarkable near 70% uptake, some 15, 000 enrolled dyads and a 1% pick up rate later and once can’t help but feel that this particular line on the map isn’t perhaps as entrenched as some predecessors’ have been. See page 26

A half full/half empty bottle

In what can only be described (and lauded) as a courageous study by all involved, Elizabeth Henderson and colleagues in Glasgow, Scotland tested the predictive value of erythrocyte membrane bound phosphatidyl ethanol (PAE) as a marker of maternal alcohol intake in the weeks leading to delivery. Why is this important: hasn’t the horse already bolted by delivery? No, this isn’t the case. There are implications for an early diagnosis that current genetics can’t better for faster intervention and for intervention to both born and yet to be conceived siblings. There are alternative markers: maternal blood, urine, and hair (poor sensitivity) and meconium (fatty acid ethyl esters and ethyl glucuronide) which are sensitive but non-specific and, therefore, limited predictively and logistically.

The analysis this study was (like INGR1D) undertaken on routine day five blood spot cards and validation made against the gold standard self -reported late pregnancy alcohol intake: in this particular arena, that’s as good as it gets especially when the return rate is close to 100%. Neither the modest or moderate (8 and 20 ng/mL) cut offs performed well, at least not at the levels where this could be recommended as a screening tool. The idea, though (using blood spots) is admirable and has now proven to be practical and the study yet more fuel to my ‘negative’/Null studies as useful as ‘positive’ bias. But I would say that wouldn’t I – sticking to boundaries… See page 36

Medicins SANS Frontieres perhaps

So, what happens when barriers are stripped away? When these cross traditional professional boundaries, that’s when real progress happens. Alan Rogol’s (Charlottesville, USA) wonderful history (and celebration) of a century of insulin treatment, a testament to collaboration, basic science, spirit and humanity encapsulates this construct to a tee. See page 3